Operators in 490 board and care facilities completed two questionnaires about their facilities’ characteristics and policies. These data suggest that there was enormous diversity among places known as board and care homes in size, price, setting, service mix, resident mix, and available services. This chapter presents our findings on these facility characteristics. We also examine whether there were significant differences between licensed and unlicensed facilities and licensed extensively regulated homes and licensed homes in States with limited regulations.

3.1.1 Size

The widespread perception that board and care homes are small, “homelike” settings is misleading. The facilities in our study ranged in size from places with 2 beds to those with more than 1,400 and included family homes as well as multilevel facilities that also had congregate apartments and a skilled nursing home. More than 70 percent of the licensed and nearly 50 percent of the unlicensed homes were small (Exhibit 3-1). However, in licensed homes, 25 percent of the residents lived in medium-sized homes (11-50 beds), and 52 percent lived in large, licensed homes (51+ beds). Among residents of unlicensed homes, more than 80 percent lived in large facilities. These large unlicensed homes included assisted living facilities and retirement communities that provide meals, protective oversight, and some services.

3.1.2 Ownership and Affiliation

Less than 20 percent of all facilities were nonprofit, with licensed facilities being less likely to be nonprofit than unlicensed homes. Specifically, only 15 percent of small licensed homes were nonprofit compared to almost 40 percent of small unlicensed homes (Exhibit 3-2). In looking at licensed facilities, we observed that licensed homes in extensively regulated States are less likely to be nonprofit than those in States with limited regulations.

Overall, less than 10 percent of board and care homes were attached to nursing homes (Exhibit 3-3). Virtually no small homes reported affiliation to a nursing home compared to almost one-third of the large homes. However, licensed homes in States with limited regulations are twice as likely to be attached to nursing homes (see Table A-9).

Perhaps an indication of the rapid growth experienced by the board and care industry recently is the fact that about one-third of the operators reported owning or operating another board and care facility in addition to the one included in the study. Almost 10 percent reported owning or operating a nursing home.

3.1.3 Occupancy Rates and Revenue

We observed no consistent differences in occupancy rates across various types of facilities, with the average occupancy rate being about 80 percent. Although the occupancy rates were similar, we found that the average monthly revenue per resident in licensed extensively regulated homes was over $300 higher than in licensed homes in States with limited regulations. In particular, licensed small and medium homes had significantly higher average per-resident monthly revenue than did comparably sized unlicensed homes (Exhibit 3-4).

3.2.1 Medication Management

Because a large proportion of board and care residents take prescription medication, it is particularly important for facilities to have appropriate medication management practices. Licensed and unlicensed homes reported significantly different practices. Regardless of size, licensed homes were more likely to allow at least some residents to manage their own medications (Exhibit 3-5).

Board and care facilities varied immensely on criteria for admittance to their facilities. Almost half of the facilities reported that they would not admit residents who were mobility-impaired. Twenty-three percent would not admit incontinent residents, and 19 percent would not admit SSI recipients. Almost all facilities reported accepting residents with behavior problems (Exhibit 3-6).

However, perhaps even more important to a resident who wishes to “age in place” is a facility’s discharge policy for residents who develop debilitating conditions while residing in the facility. We asked operators who reported that their facility did not admit residents with certain characteristics (e.g., incontinence, mobility impairment) whether the facility would discharge a resident who develops the conditions after being admitted to the home. Seventy-five percent of the facilities that did not admit mobility-impaired residents (35 percent of all facilities) reported discharging residents who became impaired while living in the home. Less than 10 percent of all facilities reported discharging residents who became incontinent, developed behavior problems, or started receiving SSI after moving to the facility.

Differences by Regulatory Environment. There were no differences in admission or discharge policies by regulatory environment, with the possible exception that licensed homes in extensively regulated States were significantly more likely to report that they will admit “no” SSI residents than was the case in limited regulation States (21 percent vs. 10 percent) (see Table A-11).

Differences by Licensure Status. We also examined resident admission and discharge policies for licensed homes compared to unlicensed. Large licensed homes were significantly less likely to admit mobility-impaired residents and were more likely to discharge them than were their unlicensed counterparts. Although licensed homes were somewhat more likely to report admitting SSI-funded residents than were unlicensed homes, almost no homes reported discharging residents once they became SSI recipients (see Table A-3).

As the board and care population becomes increasingly impaired, the experience, training, and knowledge of staff who care for them become more critical. An examination of facility staffing factors raises concerns about quality.

3.3.1 Staff Training Required by Facility

Nearly 20 percent of the operators in licensed homes and 33 percent in unlicensed homes reported that they did not require training for staff (Exhibit 3-7). Of those who required training, only 23 percent of licensed homes and 15 percent of unlicensed homes required staff to complete all training before they began providing resident care (i.e., preservice). Another 35 percent of operators in licensed homes and 22 percent in unlicensed homes reported that they required some preservice and some on-the-job training for staff.

There were large differences in the number of hours of training required of board and care staff in licensed homes in extensively vs. limited regulation States. Over half of those in extensively regulated States required 2 or more days of training compared to about one-third in States with limited regulation (Exhibit 3-8).

On major area of concern relates to staff qualifications and medication usage in board and care homes. As noted in Section 3.6, virtually all homes reported providing medication storage or supervision. In addition, three-quarters of the residents reported receiving assistance with medications, and many were taking psychotropic drugs (see Section 6.3 and Section 6.8). Despite this, only 21 percent of the homes had any licensed nurse on staff (Exhibit 3-9). This included full- or part-time nursing staff and registered nurses (RNs), as well as licensed practical or vocational nurses (LPNs/LVNs). Interviews with operators and staff showed that most staff who reported passing medications, 73 percent, were not licensed nurses even though only one State (Oregon) had a program for training and certifying nonnursing staff to pass medication. Eighteen percent reported being LPNs or LVNs, and only 10 percent were RNs. Of the staff passing medications, 26 percent reported they received no training on medication supervision or management. Of staff who reported giving injections to residents, only 21 percent were RNs, 51 percent were LPNs or LVNs, and 28 percent were not licensed nurses.

The influence of more extensive regulations was seen in the greater experience of operators and the more stringent staff training requirements they reported. Although they clearly indicate compliance with State regulations, these structural measures characterizing the training of staff are not necessarily evidence that more extensive regulation improves the quality of the home. Nonetheless, training of board and care home staff was one of the features our expert panel (TAG) felt could make a difference in the lives of the residents who are so dependent upon their caregivers.

3.3.2 Resident/Staff Ratio

In almost one-fourth of the homes, the operator was the only paid staff person. We observed no difference in the average number of residents per direct care staff as a function of regulatory extensiveness. However, there was a significant difference between licensed and unlicensed homes of most size categories. Unlicensed medium and large homes had, on average, more residents per direct care staff than did comparably sized licensed homes. The average ratio in large unlicensed homes was almost 12 times that of large licensed homes (see Table A-5).

In considering the “social environment” of the home, indicators such as operators eating with the staff or family living and/or working in the home were thought to represent more “homelike” and less institutional facilities. Although licensed home operators in a limited regulatory environment were more likely to report always eating with residents, family were more likely to always eat and live in licensed homes in the more extensively regulated States. These homes were usually a family business, although not necessarily a family home. Overall, operators and/or their families lived in almost two-thirds of the facilities (see Table A-12).

For all of these homes, the resident mix was quite complex (Exhibit 3-10). Approximately three-quarters of the homes reported having one or more residents with cognitive impairment. Over half of the homes reported having residents with a diagnosis of mental illness or prior stay in a psychiatric hospital. One-third reported having residents with mental retardation or developmental disabilities. Moreover, board and care homes also coped with more complex problems. Forty-two percent of homes reported having one or more residents with alcohol abuse problems, and 15 percent said they had residents with a past history of drug abuse problems.

Some homes also housed residents with significant health problems and functional impairments. Almost 30 percent of the homes reported having one or more residents who stayed in their room all day in bed or in a chair because of health problems, and almost 60 percent of the homes reported having residents with urinary incontinence.

3.5.1 Differences by Regulatory Environment

Board and care homes differed in their mix of residents (Exhibit 3-10). Some homes had a mainly elderly mix of residents. Over 60 percent of the licensed homes in States with an extensive regulatory system reported that residents were primarily elderly (65 and older). Only 36 percent of the homes in States with limited systems had this elderly resident mix. Other homes, even though not specifically licensed as such, housed mainly persons with persistent mental illness or developmental disabilities (MR/DD). Sixteen percent of the licensed homes in States with extensive regulatory systems and almost 40 percent in States with limited systems reported having primarily nonelderly residents, most of whom had a chronic mental illness or MR/DD. Slightly over 20 percent of licensed “extensive” homes reported having a mixed population that included the frail elderly and persons with cognitive impairment, compared to 29 percent of facilities in “limited” States.

Licensed extensively regulated homes were more likely to house chairfast, cognitively impaired, and incontinent residents than were licensed homes in States with limited regulations.

3.5.2 Differences by Licensure Status

In spite of similarities in admission and discharge policies (discussed in Section 3.2.2), the resident care mix across licensure status was considerably different (see Table A-2). Small licensed facilities were more likely to house 90 percent or more elderly residents than were small unlicensed homes. Indeed, 70 percent of small licensed homes reported housing all elderly residents compared to half of small unlicensed homes. The opposite was true in large homes, with about 75 percent of large licensed facilities reporting a primarily elderly population compared to 88 percent of large unlicensed homes. No consistent differences in case mix indicators measuring functional level or frailty were observed, although small unlicensed homes were more likely to house some residents with psychiatric histories than were small unlicensed homes. Finally, compared to unlicensed homes, licensed homes, particularly small and large facilities, had significantly higher proportions of residents who were SSI recipients.

To meet the needs of the complex mix of residents, some board and care homes offered a wide range of services. However, available services varied considerably from homes offering little more than room, meals, oversight, and a few services to places that provided or arranged for extensive and skilled nursing services and therapies.

3.6.1 Service Mix

More than three-quarters of the homes reported providing medication storage or supervision, organized activities, recreational trips, and transportation (Exhibit 3-11). Approximately one-quarter of all homes reported providing nursing services.

Differences by Licensure Status. By and large, licensed homes of all sizes were significantly more likely to provide therapy directly to their residents than were unlicensed homes. A “responsible” person is more likely to be present in medium and large licensed homes than in comparably sized unlicensed homes, and large licensed homes are more likely to provide transportation than are large unlicensed homes. Regardless of size, licensed homes were more likely to report providing personal care services. A similar pattern is observed for medication reminders and medication storage (see Table A-7). The average number of health services in a facility was greater in licensed homes of all sizes (Exhibit 3-12). Social services were more prevalent in large licensed homes than in comparably sized unlicensed homes (4.2 compared to 2.9).

With respect to arranging for outside services, the differences were not as consistent. Although small licensed homes were more likely to arrange for nursing and long-term care for their residents than were small unlicensed facilities, large licensed facilities were more likely to arrange for outside transportation for their residents than were large unlicensed homes; most other externally arranged services did not consistently differ by licensure status.

Differences by Regulatory Environment. The pattern of service availability in licensed facilities in limited and extensively regulated States was remarkably similar. We observed few significant differences. Licensed homes in limited regulation States were more likely to manage their residents’ money (64 vs. 31 percent) and to provide medication reminders (90 vs. 79 percent) than licensed homes in extensively regulated States (see Table A-15).

EXHIBIT 3-12. Average Number of Health Services Provided by the Facility by Size and Licensure

3.6.2 Services from External Agencies

Half the homes reported that outside agencies, such as home health agencies, provided nursing care to residents who needed such care on a temporary or episodic basis. In addition, as seen in Exhibit 3-13, 25 percent of the extensively regulated licensed and 23 percent of the licensed homes in States with limited regulation reported that agencies provided ADL/personal care to residents. Approximately one-third reported that some residents attended Senior centers or adult day care programs. About 30 percent of the homes reported that some residents attended sheltered workshops or day activity programs.

No significant differences were observed in the type, or number, of outside provided services arranged by the home, except that in limited regulation States homes were more likely to arrange for sheltered workshop programs than was the case in extensively regulated homes.

3.6.3 Approach to Residents Who Need Nursing Care

Although most homes reported providing many services directly and through external agencies, homes differed on whether residents who needed nursing care could remain in the home. Part of this variation is a function of the facility’s willingness and ability to provide or arrange care. In addition, licensing regulations in some States prohibited board and care homes from admitting or retaining residents who need daily nursing care. A few States, such as Florida and Oregon, allowed daily nursing care to be provided by some classes of board and care homes. Other States limited the services such homes could provide. As a result, there was considerable variation in how homes dealt with residents who needed nursing care. Over half of all facilities reported they provided services with facility staff or arranged for a home health agency to provide care if the resident needed only temporary nursing care. However, 28 percent of the homes reported that they sent the resident to a hospital/emergency room if the resident became ill and needed temporary nursing care (less than 14 days). More than half of all homes reported they would discharge a resident to a hospital or nursing home if the resident needed nursing care for more than 14 days (Exhibit 3-14).

3.6.4 Services Covered by Monthly Rate

Homes differed in terms of the services covered by the monthly rate. These monthly rates generally cover room, board, personal laundry, special diets, and assistance with eating, dressing, and toileting in all homes. However, in over 10 percent of the homes, there was an additional charge if the resident needed a special diet or personal assistance with eating, dressing, and toileting. Nearly three-quarters of the homes charged extra for incontinence supplies (Exhibit 3-15).

3.7.1 Facility Measures

The environmental surroundings of long-term care residents enhances or detracts considerably from the quality of care and life for residents. We defined several quality measures to characterize different aspects of the facility’s physical surroundings. These measures included scores that summarized the prevalence of safety features, assistive and supportive devices, social and recreational aids, and physical amenities. To create the structural measures, we combined varying numbers of elements (ranging from 4 to 21) and then calculated a percentage score for the number of factors present. A description of these results follows.

Facilities scored the lowest on components contributing to facility safety. The average facility safety score was 58 percent, indictating that about one-third of the safety features measured were absent from the average facility. Facilities scored higher on the prevalence of assistive and supportive devices and social and recreational aids, with average scores of 65 and 69 percent, respectively (Exhibit 3-16). Average scores of 72 and 74 percent on measures of physical attractiveness and evnvironmental diversity indicated that most facilities were clean, pleasant, and at least somewhat diverse.

It is important to note that the safety measure used in these analyses does not represent a gold standard for what constitutes a “safe” facility. It presents a summary measure of the 10 characteristics that contribute to a safe environment: smoke detector, fire extinguishers, fire sprinkler, call buttons in bathrooms and bedrooms, nonskid stair surfaces, adequate lighting, presence of obstructions in the halls or on the stairs, and an outside area that is visible to the front desk (Moos and Lemke, 1978). A closer look at the components of the measure indicate that the three most frequently missing safety characteristics of the facilities in this study were fire sprinklers (only 29 percent of the facilities had working systems) and call buttons in the bathrooms and bedrooms.

Board and care homes, though perceived as substantially less institutional than nursing homes, actually varied quite a bit in terms of environmental features or practices that many observers regard as “homelike.” Board and care homes varied from places in which three or four residents shared a room to places in which residents lived in private apartments. Most had common areas, which included community rooms or living rooms and outside sitting areas, although only about half of all homes allowed residents access to a kitchen to fix a snack, a cup of coffee, or a soft drink. Homes also differed in the degree to which the environment was “homelike” or more institutional and whether residents were allowed to bring their own furniture or only a few private possessions, such as quilts, photographs, and other small mementos.

Since the role of regulation also is to prevent the occurrence of “snake pits,” we also looked at facilities to determine which had very low scores on these measures. Only 6 percent of the facilities had the lowest possible scores in one or more of these areas. Another 27 percent had inadequate or barely adequate lighting. (A total of 32 percent of the homes had such lighting, but 5 percent had other environmental problems as well.) We defined lighting as problematic if it was absent, clearly inadequate, or barely adequate (e.g., low or glaring).

3.7.2 Staff Measures

Well-trained and knowledgeable staff are essential to provide high-quality care. The average staff knowledge scores ranged from 14 to 66 percent on three different measures. Staff scored lowest on questions about the normal processes of aging and highest on questions about basic care and medications monitoring.

We asked staff members which of the following were normal processes of aging: becoming incontinent, becoming forgetful or confused, becoming quarrelsome, or being sad and depressed. Almost three-fourths of all staff members reported that it is normal to become forgetful or confused with aging; over half of the staff members said that becoming incontinent and being sad or depressed were expected with aging.

To determine staff knowledge about basic care and medications monitoring, we presented four scenarios describing changes in a resident’s condition or a resident’s reaction to medication. We then asked staff to select an appropriate course of action. We also asked staff about monitoring residents on specific medications and what side-effects to watch for. Based on answers to these seven questions the average staff score was 66 percent.

3.7.3 Use of Physical Restraints

We found that the prevalence of physical restraints, although serious, was not widespread. Fifteen percent of the staff reported use of physical restraints, an intervention that is widely viewed as inappropriate for behavior control and ill-advised as a means of addressing the possibility of falls. A similar number of staff reported witnessing other staff engage in verbal abuse, threats, or similar forms of punishment (e.g., withholding food, isolation) to address difficult behaviors among residents.

The operators’ views of the level of regulatory control were assessed in several questions about the number of inspections and whether the home operated under some regulatory corrective action.2 We observed that two-fifths of small and mid-sized licensed homes reported having experienced multiple inspections in the past year, a significantly higher rate than their unlicensed counterparts. As might be expected, licensed homes of all sizes were more likely to have been subject to corrective action in the last year than were unlicensed homes (see Table A-6).

Reflection on the “Niche” Served by Board and Care Homes. It seems clear that board and care homes do, in fact, fit in the “niche” between residential settings with few services and nursing homes. Moreover, while there is “overlap” between board and care homes and these two other modalities at either end of the continuum, it is apparent that board and care homes provide a distinct service.

In terms of services, board and care homes provided more care and services than congregate apartments and boarding houses. However, even with the addition of services provided by home health agencies, visiting nurses, and others, the average board and care home provided fewer skilled and rehabilitative services, less routine monitoring, assessment and care planning, and less nursing and restorative care than nursing homes. The fact that less than a quarter of the board and care homes had a full- or part-time RN or LPN on staff emphasizes the difference in services. Furthermore, most board and care homes, as noted, were unable or unwilling to provide nursing services for an illness that lasted longer than 14 days, and a substantial proportion reported being unable to handle even a temporary need for nursing care.

Survey Disclaimer

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.